World IVF Day – a day for hope and positivity

World IVF Day is a day to celebrate science and be hopeful.

On this World IVF Day, my message to everyone, especially to those undergoing treatment for infertility, is to stay hopeful. Scientific advancements have significantly simplified the process and improved the treatment outcome, since the first successful IVF procedure back in 1978, which resulted in the birth of Louise Brown in the UK.

If you are struggling to conceive, my suggestion is to consult an infertility specialist now and start treatment early.

When to consider ICSI?

ICSI is a specially useful embryological technique for treatment of male infertility and repeated IVF failure. ICSI is now very much a standard procedure being sued in well over half of all treatment cycles in India.

What is ICSI?

ICSI is now a well-established microinjection technique which has helped thousands of infertile men to overcome issues with sperm parameters. It is also useful in cases of fertilisation failures with repeated IVF cycles. The technique evolved in 1990’s in Belgium and since then has become established as one of the biggest discoveries in the management of infertility. Presently more than 50% IVF cycles in India and up to 63% IVF cycles in USA are ICSI cycles.

How is ICSI different IVF?

ICSI is mainly an embryological process. The process of ovarian stimulation, egg retrieval and embryo transfer remains the same as in IVF (described above). The male partner provides a semen sample on the same day by masturbation. Alternatively, sperms retrieved surgically from testis (in case of obstructive / un-obstructive azoospermia) or sperm that has been previously cryopreserved can also be used. So, technically the number of sperms required is only as many as the number of eggs that can be fertilised.

The eggs are also processed differently for ICSI, as they are first cleaned in order to clean them and remove the debris and outer cumulus cells. The eggs are screened for maturity under a microscope and the mature ones are selected for micro-manipulation or ICSI. One carefully selected sperm is injected into each selected egg using a micro-manipulator under high magnification microscope. Later the fertilised eggs are placed in the incubator and allowed to grow.

Who benefits from ICSI? Who are potential candidates for ICSI?
  • ICSI benefits all mainly men with low sperm count , poor motility or morphology
  • In cases with surgically retrieved sperms like MESA, TESA, TESE, where this is the only tool to fertilise the egg.
  • In pts with recurrent fertilisation failure with IVF.
  • In patients undergoing preimplantation genetic diagnosis.
What are various risks associated with ICSI?

ICSI revolutionised the treatment of male factor infertility enabling even males with nil sperm count to father their own genetic child. It is a fairly safe procedure. But, some studies have indicated a marginal increase in risk of congenital malformations in the offspring (six per thousand births compared to two per thousand births in general population). But it still remains to be proven if the real cause of the higher incidence of congenital malformations in such children is ICSI or just a transmission of genetic abnormalities from the male with severe sperm abnormalities.

Contact Dr Parul Katiyar for more information about ICSI and the treatment of infertility.

Tags: Male Infertility Treatment in Golf Course Road Gurgaon, Infertility Treatment in Golf Course Road Gurgaon, Male Infertility, What is ICSI, Infertility Treatment in Sushant Lok Gurgaon, IVF Treatment in Sushant Lok Gurgaon.

Five questions to ask while choosing an Infertility Clinic

We are living in an age of consumerism, and healthcare has also been affected by it. In India, several Infertility clinics and IVF centers have come up over last few years. While this has helped fill in the demand supply gap in this field bringing in much needed competition and has given more options to the patients, this has also prompted aggressive marketing by these clinics is in order to attract more patients, thereby confusing patients on how to go about choosing their doctor and treatment center. Healthcare is a very sensitive subject and we have to be able to filter the right information from all the noise in order to be able to make the best decisions for ourselves.

In my own clinical experience, I have had several couples who have consulted me for their inability to have a child, and who were confused due to information overload on the subject and vastly varying offers and claims from infertility clinics. Patients often ask me how should a patient decide which infertility clinic is best for them and what parameters should they consider when selecting an Infertility clinic for treatment. I suggest my patients to ask these five questions before selecting an infertility specialist doctor and an IVF clinic for treatment.

Question 1 – What is the real cost of IVF treatment at the center?

Nowadays there is a flurry of ads on radio, newspapers and digital platforms, several of which try to attract patients by advertising the lower cost of IVF – at times claiming to do an IVF cycle for as low as Rs 25,000 only, while at others offering one IVF cycle free with one paid cycle. The lower cost of treatment is always better for the patients. However, it is important that patients also understand the “conditions apply” clause and read in between the lines to understand the overall cost implication before making their choice on the basis of low cost alone, so that they are not taken for a ride!

It’s important to understand that a typical IVF cycle includes several steps, namely  investigations of the couple, hormone injections for 10-11 days in order to stimulate maturation of eggs, the procedure of egg retrieval and finally transfer of embryo into the lady’s uterus. Patients should understand and take into consideration the overall cost of treatment, as at times the advertised cost may not include cost of hormones and investigations which contribute significantly to the overall cost of a cycle.

Question 2 – What is the success rate of IVF at the clinic?

Another very important parameter to check is the success rate of the clinic and also understand how the claimed success rate was calculated. While the success rate for IVF do vary from one center to another, and the patients should certainly go for treatment at centers with superior pregnancy rate, it’s important to do an apple to apple comparison of success rates.

The pregnancy rates are generally much higher in younger women undergoing IVF. Similarly, success rate for IVF is much higher among infertile couples using donor eggs as compared to the ones using their own gametes. Therefore, the claimed success rates at clinics doing a lot of donor egg cycles can actually be higher than centers with a more balanced distribution of cases.

My simple advice on this point is – if a clinic offers donor egg option without any justification or declares the patient to be having poor quality of eggs based on an ultrasound report and without doing an IVF cycle, the patient should get alert and seek a second opinion before making a decision. As such there is no way to assess the egg quality based on ultrasound or blood reports, which, at best, can estimate the ovarian reserve. There is no way to evaluate the egg quality other than to take the eggs out and check them for quality in the lab.

Question 3 – What is the incidence of multiple pregnancies with IVF at the center?

The aim of any infertility treatment is to enable a couple have a healthy child. So, one should always ask what is the protocol for the maximum number of embryos transferred in a cycle at the clinic.

There is a tendency to transfer more than one embryos in a cycle, which is based on the assumption that the chances of pregnancy in a cycle increases by transferring multiple embryos. However, the best outcome of a cycle can be achieved by transferring 1 or maximum 2 properly selected embryos. Not only does multiple embryo transfer not increase the chances of pregnancy, it, in fact, increases the risk of multiple pregnancies, thereby increasing the risk to both mother and child. Multiple pregnancy is the biggest complication of IVF treatment and the risk of multiple pregnancy is directly proportional to the number of embryos transferred in a cycle.

Question 4 – How good is the IVF lab at the center?

This is an often ignored aspect while choosing an IVF center over the other. But, a well-equipped and maintained lab is a crucial factor differentiating a good IVF center from a not-so-good center. Patients should understand that a well-equipped lab with strong quality control and quality assurance program will always do more justice to their eggs, sperms and embryos and maximize their chances of pregnancy. A good IVF clinic needs to have a good embryo freezing program in order to properly manage the extra high quality embryos from an IVF cycle for possible use for the same patient in future. This helps in preserving the precious embryos and also reduces the cost of possible IVF interventions in future. Many centers claiming a low cost IVF often don’t have a good embryo freezing options for the patients.

Likewise, a properly trained and experienced embryologist also plays an important role in success of the IVF program. So, patients should inquire about the background and competence of the embryologist also while they do the background check on the treating clinician.

Question  5 – Does the center have patient support program?

This is another lesser investigated aspect while choosing an infertility clinic for one’s treatment.  In my view, availability of a good support team including fertility counselors is as important a factor as having a good infertility specialist doctor in improving the success of IVF treatment. Good counselors help the patients understand their issues holistically and helps them overcome the stress associated with infertility. This, combined with the skills and personalized attention of the treating doctor, plays an important role in improving the outcome of IVF treatment.

So, next time you see an enticing, “too good to be true” offer for IVF treatment at an infertility clinic, stop and ask yourself these five questions before falling for it. Always remember, choosing the right infertility expert and the right infertility clinic for your treatment will largely decide the outcome of your treatment!

Do write to me at if you have any questions about IVF.

Three strategies to minimize multiple pregnancies with IVF treatment

Having twin pregnancy has become almost synonymous with undergoing the IVF treatment. And, my patients often ask me if they can conceive only twins with IVF? Here I share what are the best practices to optimize the outcome of IVF treatment and minimize the incidence of twin pregnancies.

With rising incidence of infertility, IVF treatment becoming more commonly available and all the technological innovations with IVF procedure, there is an ever growing focus on minimizing the complications associated with IVF treatment. One of the common risks associated with IVF, which is also a major cause of distress among couples preparing to start IVF treatment, is the risk of multiple pregnancies. In fact, having twin pregnancy has become almost synonymous with undergoing the IVF treatment. And, my patients often ask me if they can conceive only twins with IVF? In reality about 1 in every 4-5 pregnancies resulting from ART are twins, a rate much greater than in the general population (1 in 80 pregnancies). The incidence of triplets and quadruplets is also higher among women undergoing ART. However, the majority of ART pregnancies (about 70%) are singletons.

The risk of multiple pregnancy in IVF cycle exists primarily because of the tendency to transfer more than one embryo inside the uterus to increase the chances of pregnancy. This is done as there are no tests or procedures which can assure us of pregnancy after IVF. The process of implantation of an embryo in the womb is a complicated one, and what  transpires between the embryo and the womb that results in positive or negative pregnancy outcome is not fully understood. Therefore, in order to increase the chances of transferring an appropriate embryo, more embryos are transferred at a time. But, this puts the woman at risk of multiple pregnancy. But this does not mean that in the pregnancy rates increase proportionately to the number of embryos transferred. In fact, rather that increasing the overall pregnancy rates, transferring more than one embryos in one cycle actually increases the risk of multiple pregnancies, as more than one embryo may implant at a time.

Having twins may actually even sound tempting to many patients who have struggled to have a baby for long, but it is not as good as it sounds. Multiple pregnancy is associated with a higher rate of maternal, fetal and neonatal complications and is now considered as the single biggest risk of fertility treatment. Good practice in IVF aims to reduce risk of multiples in an IVF, whilst maintaining the overall chances of becoming pregnant. This is achieved by proper patient selection and counselling. I follow these three simple strategies to achieve the best clinical outcome from IVF procedure –

  1. Young women who have the best chance of conception also have the highest chance of conceiving multiples, so I prefer to do single embryo transfer in these patients. The remaining embryos can be frozen and preserved for later use
  2. An extended culture of embryos up to the day 5, called as blastocyst culture, allows us to select the best embryo for transfer, thereby improving the chance of pregnancy with single embryo transfer.
  3. For carefully selected set of women, who have had multiple IVF failures and who are not fit or willing for blastocyst culture, I transfer two high quality embryos, which gives the best possible chance of pregnancy with minimum possible risk of multiple pregnancies.

To sum it up, we need to counsel all our patients that only success parameter in any IVF cycle is a healthy baby born to a healthy mother, and reducing the number of embryos transferred in a cycle is a significant step in achieving this objective. Patients should be counselled about the risks associated with transferring many embryos and also explained the option to freeze the spare embryos, if any. If needed, subsequent cycles with both fresh and frozen embryos would give them even better cumulative pregnancy outcome than putting in several embryos in one cycle itself.

Do write to me at if you have any questions about IVF.


Management options for Endometrioma associated with Infertility

Endometriosis is a problem often associated with infertility. In my clinical practice I have seen many women with endometriosis who have to undergo a battery of investigations and try several treatment options to overcome the pain, dysmenorrhoea and infertility associated with endometriosis.  A significant number of these women also present with cyst in their ovary which are called as endometrioma.

Endometriomas have most commonly been treated surgically. But, while surgical treatment for endometrioma is very common, surgical treatment has no clearly documented role in improving fertility of women undergoing surgical intervention for endometriotic cyst. Surgical treatment for endometrioma in infertile patients should be reserved only for a small section of young women, as it improves spontaneous pregnancy rate among young women. However, surgical treatment has no definitive advantage over expectant management in majority of women with endometrioma and it may actually reduce a woman’s ovarian reserve .Some of the other indications of surgical intervention in infertile women with endometrioma include cysts blocking access to ovary for egg retrieval during IVF, to treat concomitant pain symptoms or in cases where malignancy cant otherwise be ruled out with reasonable accuracy.

Women with endometrioma generally have lower ovarian reserve than their age matched control group. Therefore, I recommend proceeding directly to IVF in order to reduce time to pregnancy. Despite of a negative impact on ovarian reserve and ovarian responsiveness, the results of IVF treatment in women with infertility associated with endometrioma are comparable to overall results of IVF in women with tubal factor infertility.

This also holds true for all women with endometriosis associated infertility, especially when the disease is of significant severity. I recommend aggressive treatment of infertility in these women for the best outcomes, because the chances of spontaneous pregnancy in these women are rather low.

Please write to me at if you have any questions on endometrioma and associated infertility.




IVF – A blessing or a bane?

Many patients who have been advised IVF treatment wonder if they will have a normal baby at the end of it and if the IVF carries higher risk of certain disorders. Education from credible and scientific sources helps bust several myths on this subject.

As an IVF specialist I often come across questions from my patients about safety of IVF procedure and the well being of the offspring resulting from IVF. Many patients ask me if the IVF baby could, in any way, be different from a normally conceived baby, and are, at times, reluctant to undergo the fertility treatment. Many of these patients quote some horror stories of other patients who have undergone IVF.

What I explain to the patients is that most of the times they get to hear just one side of the story. I try to make them understand that IVF is a medical procedure used to help couples conceive who find it difficult to conceive for several biological reasons. Just like all other medical interventions, IVF also has its own set of disadvantages, and can, at times, cause inconvenience to women undergoing treatment.

If you have been recommended to undergo IVF as the best way to conceive, I suggest you  not to form any preconceived opinions about the procedure based just on hearsay. Instead, you should discuss the pros and cons of the procedure, possibility of its success and chances of any inconvenience etc with your treating specialist and to educate yourself about the science behind the procedure from authentic sources. As Benjamin Franklin once said – “An investment in knowledge pays the best interest”!

I will continue to write on this subject to answer some frequently asked questions and address the common myths about fertility treatment, specially using IVF. Do write to me at if you have any questions about IVF.

Five frequently asked questions about genetics of Recurrent Pregnancy Loss

Miscarriage is a very traumatic experience for any woman or couple and can often mean loss of hope for couples finding it difficult to conceive. Recurrent miscarriages, also known as Recurrent Pregnancy Loss (RPL) is naturally even more distressing and worrisome for the affected couples. While a lot about the causes and reasons for RPL still remains mystery, we know that genetic factors play a significant role in causation of RPL. This aspect of RPL is not generally well understood by the affected couples owing to the complex science behind the same. This article is an effort to explain the genetics of RPL in simple language to bridge the gap in knowledge for the common people on this subject.

Over last ten years, I have consulted and counselled hundreds of couple who have suffered pregnancy loss, either in form of miscarriages or stillbirths. Miscarriage (also known as pregnancy loss) is a relatively common problem encountered in up to 15 to 25 % of all clinically recognized pregnancies, and in many of these cases the actual cause of pregnancy loss remains unidentified.

Most of the miscarriages are sporadic in nature and can be attributed to defects within the fetus. However, some woman may lose their pregnancy repeatedly. Recurrent pregnancy loss (RPL) is defined as loss of three or more consecutive clinically recognized pregnancies and affects around 1% of couples actively trying to conceive. RPL causes significant anxiety for the suffering patients, especially for the pregnancies resulting from fertility treatment. In addition, RPL in patients undergoing fertility treatment also causes significant financial stress for the couple.

Both Maternal age and number of previous miscarriages independently increase the risk of miscarriage in the subsequent pregnancy. However patients with RPL still have a remarkably good prognosis for live births. Also, the overall incidence of pregnancy loss with IVF pregnancy is almost same as in wider population.

The real cause of RPL remains unknown in up to 50% of the women, despite of all the advancements in diagnostics. The known causes of RPL include –

  1. Genetic Causes
  2. Immune Causes
  3. Anatomical Causes
  4. Hormonal Causes
  5. Environmental and occupational causes

While genetic abnormalities in the fetus are known to cause up to 50% of sporadic early pregnancy losses, only about 2 to 5% cases of RPL can actually be attributed to genetic abnormalities in the fetus. In this article, I will focus only on  understanding of genetics of reproduction and genetic causes of RPL. I will discuss other causes and management of RPL in my upcoming posts.

Here are five things you need to know about the genetic causes of RPL

  1. What is a chromosome?

The basic genetic unit of human body is “DNA”, which is packed together to form “Gene”. Genes are the working sub-units of DNA and carry the information that determines the features or characteristics passed on from one generation to another. Human beings are estimated to have between 20,000 to 25,000 genes. Genes are located inside the nucleus of cells and are found on thread like structures, known as which are the “Chromosomes”.

Chromosomes are arranged in pairs inside nucleus of the cells. Each human cell normally contains 23 pairs of chromosomes, with one chromosome of each pair inherited from one of the parents. The first twenty two pairs of chromosomes are same in both men and women, and are known as “Autosomes”. The 23rd pair is known as the “Sex chromosomes” and is   identified as either “X” or “Y” chromosome. The type of sex chromosome determines the gender of the person, with females having two X chromosomes and males having one X and one Y chromosome.

Every person has got 2 copies of each gene, one inherited from each parent. While most of the genes are same in all individuals, a small number of genes (< 1%) are unique for each individual and these genes eventually make all human beings individual.

  1. What is cell division?

In order to grow and reproduce the cells have to continuously divide to produce “daughter cells”. This cell division can be of two types- mitosis or meiosis. Without getting into technicalities, it would suffice here to know that the sex cells (both male and female) divide by meiosis and one cell produces four cells (known as gametes – eggs in women and sperms in men) at the end of the division.

  1. How is the fetus formed?

An embryo is formed when the egg and sperm meet each other and the sperm penetrates the wall of the egg, thus bringing its own genetic material into the genetic material of the egg. This process, known as fertilization of the egg, produces a cell with full set of genetic material (23 pairs of chromosomes) for the offspring. The embryo thus formed multiplies repeatedly and very quickly to create a mass of cells, which then differentiate to form different organs of the future baby.

  1. What are common genetic anomalies which can cause RPL?

A variety of genetic factors can cause pregnancy loss. The commonly known causes include-

  1. Aneuploidy- an extra number of chromosome
  2. Translocation and inversion of chromosomes- fault in structure of chromosome
  3. Deletion or duplication of chromosome- fault in amount of DNA in a chromosomes
  4. Single gene mutations- chromosomal abnormality at the level of genes

Aneuploidy – Aneuploidy is an error of cell division, which results in the “daughter” cells having wrong number of chromosomes. In some cases there is a missing chromosome, while in other cases, there is an extra chromosome inside the cell. Thus, such individuals with aneuploidy may have cell with 45, 47, or 48 chromosomes. Such individuals will have cells with improper genetic information, which can result in miscarriages. In some cases with aneuploidy (as in cases of Down’s syndrome), the fetus may survive but the child is likely to be born with various abnormalities. The most common aneuploidies are extra chromosome number 16, 18, 21.

Translocation – In translocation, a segment from one chromosome is transferred to another chromosome or to a new site on the same chromosome. Translocation could either be non-reciprocal, in which there is a one way migration of chromosomal segment or reciprocal, which involve exchange of segments from two different chromosomes. Translocation leads to alteration in the alignment of the genetic structure of the fetus and could, in some cases, result in miscarriage.

Inversion – An inversion is a chromosomal rearrangement in which the affected segment of a chromosome is reversed end to end, and typically occurs when a single chromosome undergoes breakage and rearrangement within itself.

Inversions and translocations may not cause any genetic abnormalities in carriers (parents), as long as the rearrangement is balanced with no extra or missing DNA. However, the gametes (eggs and sperms) in affected people carry unbalanced (excess or insufficient) amount of genetic material. The resultant pregnancy is, therefore, genetically abnormal and can lead to infertility, recurrent miscarriages and sometimes increased risk of cancer.

Deletion and Duplication of Chromosomes – In deletion, a portion of the chromosome is missing or deleted, whereas in duplication, a portion of the chromosome is duplicated, resulting in extra genetic material. Both these genetic abnormalities can lead to various kinds of syndromes in the offspring.

Single gene mutation – Single gene mutations are caused  by DNA alterations within one particular gene. These mutations can affect the mother or the fetus.

Mutations in the mother can interfere with implantation of the fetus, thus causing infertility or recurrent miscarriage. Some examples of maternal single gene disorders include maternal myotonic dystrophy, connective tissue disorders like Marfan Syndrome and Ehler Danlos Syndrome and sickle cell disease.

Single gene mutations in fetus, which could lead to RPL include autosomal dominant lethal skeletal dysplasia, Type 2 osteogenesis imperfecta, autosomal recessive disorders like Alpha Thalassemia and X chromosome linked disorders which typically are lethal in male fetus.

  1. What are chance of live birth after RPL

The chances of having a live birth after recurrent miscarriages are not as grim as they appear. The overall probability of live birth after RPL for women aged between 30 and 34 years of age is approximately 66- 70%. The probability, however, goes down with each extra pregnancy loss beyond 3 and increasing maternal age. Newer technologies like “Preimplantation Genetic Diagnosis” (PGD) can help in improving the chances of live birth in couples with known genetic disorders, as it helps in selecting the embryos with the correct genetic composition before transferring into the uterus.

Thorough evaluation of couples who have already encountered miscarriages in two consecutive pregnancies is recommended, because the risk of another miscarriage after 2 lost pregnancies is already almost 30% compared with a risk of miscarriage of 33% after 3 lost pregnancies.

Please write to me at if you have any questions related to RPL or if you need more information on this subject.

Seven frequently asked questions on “Poor Ovarian Reserve”

Poor ovarian reserve is a major cause of reduced fertility among women who delay planning a family. Many of these women remain unaware of this reality and dont know that there was means to preserve their eggs for a delayed child bearing.

Ovarian Reserve is one of the more frequently discussed topic in my infertility practice, especially as many working women plan to defer child bearing while they remain worried about their fertility potential in future. Besides this, I see a lot of women who are not able to conceive and have poor ovarian reserve. Here are seven most frequently asked questions related to “Ovarian Reserve” and my answers to these.

  1. What is ovarian reserve?

Ovarian reserve of a woman is defined as an estimated number of oocytes/ eggs a woman has in her ovaries at a given time. A female fetus has a maximum of 6 to 7 million eggs at 16 to 20 weeks of gestational age. Thereafter, this number keeps on declining and reaches an approximate count of 1 to 2 million eggs at the time of birth, and further falls to approximately  250,000 to 500,000 eggs at puberty. This count further declines to approximately 25,000 at around 37 years of age and to less than 1000 at menopause.

  1. How is ovarian reserve estimated?

There are various tests to assess ovarian reserve. The main tests include –

  1. Serum FSH/LH- done on the 2nd /3rd day of a woman’s menstrual cycle gives an indication of the woman’s egg reserves.
  2. Serum Anti mullerian hormone (AMH) – very sensitive test of testing a woman’s ovarian reserve. It can be done on any day of the menstrual cycle.
  3. Antral Follicle count-  Antral follicle are small follicles present in the ovary that are best seen during the early phases of the menstrual cycle. Transvaginal ultrasound (TVS) of the pelvis is used to count the number of antral follicles, which gives good estimate of the woman’s ovarian reserve.AFC

    3.  Why is testing for ovarian reserve important?

A woman’s ovarian reserve is an indicator of her fertility potential. Women facing difficulty in  conception or planning to delay child bearing should be assessed for their ovarian reserve for timely and appropriate fertility intervention.

  1. What is poor ovarian reserve?

If a woman has a premature decline in her egg quantity due to any reason which reduces her chances of having a mature egg, she is suspected to have “poor ovarian reserve”. It is natural for the number of eggs present in a lady to decline as she ages – both due to ovulation and a natural cell death process called “Apoptosis” – and normally the woman would exhaust her egg reserve by the time she reaches menopause. But, if the decline in egg count happens faster than that and the woman is depleted of her egg reserve before expected menopause, she should be suspected to have “poor ovarian reserve”.

  1. What causes poor ovarian reserve?

Poor ovarian reserve can be caused by a number of reasons-

  1. Genetic defects including chromosomal anomalies such as Turner’s syndrome and gene defects like Fragile X syndrome.
  2. Damage to the ovaries due to any injury, torsion, infection, surgery or due to radiation or chemotherapy.

However in most cases the exact cause of poor ovarian reserve remains unknown.

  1. Does poor ovarian reserve lead to reduced chances of pregnancy?

Poor ovarian reserve is associated with reduced chances of pregnancy both naturally and following fertility treatment. This is because the number of eggs is reduced which corresponds to reduced chances of pregnancy. The goal of ovarian reserve testing is to identify those individuals who are at risk of diminished ovarian reserve so that they can be encouraged to pursue more aggressive treatment to achieve pregnancy.

  1. Is there any treatment to improve the ovarian reserve?

There are no concrete remedies to improve Ovarian reserve however lately some medications have been developed  to improve the egg quality and number. The benefits of these medicines are not yet conclusively proven.

preventing failure

You can read more about management of Poor Ovarian Reserve at

Dr Parul Katiyar 

For more information on poor ovarian reserve and ways to address poor fertility resulting from this, please write to me at


IVF treatment and twins – role of multiple embryo transfer

One of my patients whom I was counselling for IVF treatment for her primary infertility recently asked me a very basic question about the procedure and its outcome. She asked me – “Doctor, can I conceive only twins with IVF?”. This again prompted me to think about this very important aspect of fertility treatment – the risk of multiple pregnancy resulting from multiple embryo transfers. Some big celebrities like Celine Dion, Julia Bradbury and Jennifer Aniston and our own Farah Khan have been in news for conceiving multiple babies with IVF and that somehow makes many women undergoing IVF treatment to think that IVF produces multiple pregnancy only.  In this post, I  will try to explain the reasons for multiple pregnancies resulting from IVF treatment and how can this be avoided.

According to global evidence, approximately 25% of total births resulting from ART treatment are twins, a rate much greater than in the general population (approximately one in 80 births). The incidence of triplets and quadruplets is also high among pregnancies resulting from IVF treatment. However, the majority (approx. 70%) of pregnancies resulting from IVF treatment are singletons. With an ever increasing focus on optimizing treatment outcome and reducing complications associated with IVF treatment, the risk of multiple pregnancies with IVF has become  one of the most important considerations while planning the IVF cycle.

The process of implantation of an embryo in the womb is a complicated one and we still do not know what transpires between the embryo and the uterus when they come in contact with each other, and therefore, we do not completely understand the reasons for a positive or negative pregnancy outcome also. Since there is no test or procedure that can assure pregnancy with IVF – an expensive treatment not generally covered by insurance policies – the physicians naturally want to enhance the probability of pregnancy and consider putting in more than one embryos. The risk of multiple pregnancy in IVF cycle derives from this tendency among treating physicians to transfer more than one embryos inside the uterus in order to increase the odds of pregnancy.

Pregnancy rates with IVF treatment appear to peak with transfer of three or four embryos. However, the risk of multiple pregnancy also increases at the same time. Multiple pregnancy is associated with   a higher rate of maternal, fetal and neonatal complications and is considered as the single biggest risk or complication of fertility treatment.

Good practice in IVF treatment aims to reduce the risk of multiple pregnancy whilst maximizing the overall chances of conception. This is achieved by proper patient selection and counselling.

  1. Young women who have the best chance of conception, also have the highest chance of conceiving multiples. Therefore, I always offer them a single embryo transfer at a time and freeze the rest of the good quality embryos for later use.
  2. An extended culture of embryos up to the day 5, called as blastocyst culture, helps in better embryo selection for transfer into the uterus. I advise blastocyst culture for patients with more than 3 good quality embryos and transfer a single blastocyst in such patients.

I also believe that treating physicians should counsel the patients that only success parameter in any IVF cycle is a healthy baby born to a healthy mother and reducing the number of embryos transferred in a cycle is a significant step to achieve that goal. Patients should be counselled about the risk associated with transferring many embryos and also explained that freezing the spare embryos and transferring them in subsequent cycles if needed  would give them even better cumulative pregnancy outcome than putting back many embryos in one embryos transfer.

Please contact me at for any queries related to IVF or any aspect related to infertility treatment.

Does infertility treatment put women at higher risk of cancers?

Many patients ask me if IVF treatment leads to a higher risk of cancers, especially in breasts and ovaries. As per the latest published scientific literature on this subject, there is no real evidence to link IVF with higher risk of cancers among these women.

As an infertility specialist, I am required to counsel mcancery patients about potential complications of fertility treatment. One of the most often asked question is if infertility treatments put the women at a higher risk of cancers.

Fertility drugs like clomiphene citrate and hormones used for ovarian stimulation & assisted reproductive technologies like IVF and ICSI have all been implicated to causes various cancers among women, including not only cancers of cervix, uterus, ovaries and breast, but also melanoma and cancers of the central nervous system.

A simple answer to this question is that as per the latest studies, there is no conclusive evidence to suggest a higher risk of invasive cancers in women receiving infertility treatment.

Why has infertility treatment been linked with higher risk of cancers?

There are multiple theories as to why fertility treatment may increases the risk of cancer in women.

  1. Hormonal treatment with Clomiphene and Gonadotropins causes cancers because elevated levels of estrogen and progesterone hormones can trigger carcinogenic activity in the ovarian , uterine and breast tissues
  2. Ovarian enlargement due to development of multiple follicles causes trauma to the ovaries, which may result in carcinogenesis.
  3. Injury to ovaries resulting from multiple needle punctures made during egg retrieval has also been suggested to cause cancers of ovaries.

However, at the same time, it has also been suggested that infertile and nulliparous women are inherently at an increased risk of certain cancers so actually infertility treatment may not be the cause of cancers in these women.

What does the scientific evidence tell us?

Extensive research has been conducted on this subject, but the results so far have been pretty inconclusive. We need to appreciate that it is indeed difficult to study direct relationship between cancers in women and infertility treatment because many of these cancers appear many years after the treatment/ causative injury. Therefore, large populations have to be studied over a long period of time in order to arrive at any meaningful conclusions regarding the relationship between fertility treatment and cancers.

Of all the cancers suspected to be associated with infertility treatment, cancers in ovaries are most often linked to the infertility treatment. The overall evidence in this regard is mixed. While some studies have found the risk of ovarian cancers to be higher in women with a history of fertility treatment, others have ruled any such association out.

A research group from Israel retrospectively studied possibility of such an association in over 106,000 women, who had delivered between 1998 and 2013.1 The researchers found that women with conceived with IVF treatment had a significantly increased risk of being diagnosed with ovarian and uterine cancers as compared to women who had conceived either naturally or using ovulation induction. However, another study of over 87,000 women from Israel only conducted around the same time did not find any significant relationship between IVF exposure and risks of breast, endometrial, or ovarian cancers.2

In a population based cohort study of 812,986 women from Norway, who had delivered between 1984 and 2010, the researchers tried to assess the overall risk of cancers and specifically of cancers of cervix, uterus, ovary, thyroid, the central nervous system and melanoma among the women who had conceived using ART. 3 They found that the overall risk of cancers was not higher among the women conceiving using ART and delivering at least one baby. Although there was a hint of higher incidence of some cancers among women undergoing IVF, this could not be statistically proven owing to the weak nature of this kind of population based study.

A Cochrane review of 25 studies (consisting of 11 case-control studies and 14 cohort studies) covering 182,972 women did not find any convincing evidence supporting an increased risk of invasive ovarian tumors with fertility drug treatment. However, the researchers concluded that there may be an increased risk of borderline ovarian tumors in subfertile women treated with IVF.4

Cancer of the breast is the second most commonly discussed cancer that is assumed to be linked with hormonal treatment for infertility. Large studies and meta-analyses have not found any significant correlation between treatment for infertility and breast cancer. 5,6 While some studies have suggested that the risk of breast cancer increases after exposure to ovulation inducing agents (especially clomiphene citrate)6, many other studies do not support such an association.5 Therefore, I don’t advocate long term administration of Clomiphene, as the risk of breast cancer is not fully ruled out with its long term use.


Overall we can say that on the basis of existing scientific evidence, there is no conclusive proof of a causal link between ovarian and breast cancers and fertility treatment. Therefore, treatment of infertility using hormones and ART is by and large safe. The cancers of ovary and breast detected among women with history of treatment for infertility are more likely to be related to their infertile status than to the effect of fertility drugs. However, we must keep in mind that majority of the available studies on this subject suffer from methodological limitations and therefore cannot be fully relied upon. Further research on this subject will certainly enlighten us more on the possibility of any such association.


1.       The risk of female malignancies after fertility treatments: a cohort study with 25-year follow-up. Kessous et al. J Cancer Res Clin Oncol. 2016 Jan;142(1):287-93.

2.       In vitro fertilization and risk of breast and gynecologic cancers: a retrospective cohort study within the Israeli Maccabi Healthcare Services. Brinton et al. Fertil Steril. 2013 Apr;99(5):1189-96.

3.       Cancer risk among parous women following assisted reproductive technology. Reigstad et al. Hum Reprod. 2015 Aug;30(8):1952-63.

4.       Risk of ovarian cancer in women treated with ovarian stimulating drugs for infertility. Rizzuto I, Behrens RF, Smith LA. Cochrane Database Syst Rev. 2013 Aug 13;8:CD008215.

5.       IVF and breast cancer: a systematic review and meta-analysis. Sergentanis et al. Hum Reprod Update. Sergentanis et al. 2014 Jan-Feb;20(1):106-23.

6.       Breast cancer incidence after hormonal treatments for infertility: systematic review and meta-analysis of population-based studies. Gennari et al. Breast Cancer Res Treat. 2015 Apr;150(2):405-13.

For further information or queries on this subject, please write to me at

Dr Parul Katiyar